10 pieces of advice for new physicians

I am blessed to love being a doctor. As the child of two physicians, and the fifth generation of physicians in my family, I had no choice but to go to medical school. But from the first day of medical school, I loved it. What a privilege, to know how the human body works! And I didn’t think medical school was particularly fun: I thought it was hard. The first two years were a blur of drudgery and memorization.

But like learning a foreign language, after years of memorizing grammar, pronunciation, and vocabulary, this drudgery was transformed into beauty. I could grasp the poetry of differential diagnosis, the link between the history, the physical examination, the laboratory findings, and the treatment plan.

What excites me most now about medicine is the patient interactions, and trying to instill good habits of lifelong learning and fastidious attention to detail to physicians in training, as well as advice on how to use common sense and to communicate effectively with patients.

So, in that vein, here are my top 10 pieces of advice for physicians in training.

1. Learn the art of calling a consult. First, call the consult early in the morning. The consultants have lives, just like you. The earlier you call them in the day, the easier it will be to fit the patient into their schedule (and the nicer they will be when called.) Second, have a specific question for the consultant. So, don’t ask the hematologist to see your patient for anemia. Ask the hematologist if the anemia you have diagnosed, in the setting of a low reticulocyte count along with a low-normal white blood cell count and platelet count, merits further investigation such as a bone marrow biopsy.

2. Never do a test that won’t change your management. As we all know from Bayes’ theorem, the pretest probability affects the post-test probability. So if you have a 20-year-old woman with chest pain after eating chili, and you order a stress test on her, and it’s positive, the chances of a false positive are higher than the chances of a true positive, and you’re worse off than when you started; because now you have to explain to the patient why you are ignoring the result of a test you ordered.

3. Manage expectations. If a patient is admitted the hospital with urosepsis and you tell them they will likely be there 7 days, and they leave in 5, they will think you’re the best doctor ever. If you tell them they will likely be there 3 days, and they leave in 5, they will think you’re the worst doctor ever. It’s not the reality; it’s the expectation. Even better, use discharge criteria instead of time: you will leave when you no longer have a fever, and we identify the appropriate oral antibiotic from your culture results.

4. When explaining medical facts to patients and families, pretend you’re talking to your non-medical best friend, parent, or spouse. It’s easy, after you’ve taken all the time and trouble to learn the foreign language of medicine, to use words like afebrile and renal failure when you talk to patients. But if you wouldn’t use those words with your (non-medical) friend, parent, or spouse, don’t use them with the patient.

5. Less is more. Never give a hospitalized patient medication intravenously if you can give it orally (like potassium or magnesium supplementation, pain medications, or antibiotics). Never give hospitalized patient supplemental oxygen if they don’t need it; so if the patient is on 4 L nasal cannula, figure out if they really need it. Never keep a Foley catheter in if the patient can use the urinal, commode, or restroom.

6. The best way to pre-round is to know what orders were written overnight, what PRN medications were given, and to read the nursing notes. Pretty much nothing important can happen if it’s not in the nursing notes or if it didn’t involve a new order or medication.

7. Know the difference between a chief complaint and an admitting diagnosis. If you admit a patient with a bleeding gastric ulcer but what really brought them to the hospital was severe knee pain (which caused them to take the NSAIDs, which caused the bleeding ulcer), don’t discharge them without addressing the knee pain. It might just be routine, benign, osteoarthritis to you, but if it’s bad enough that they’re taking way too many NSAIDs, it needs to be addressed.

8. Don’t be afraid to tell the patient you don’t know the answer. I often tell patients that if I don’t know the answer to their question, then I will help them find someone who does (see the art of calling the consultant, above). And sometimes, there is no answer, and it’s a matter of reassuring patients that their symptoms, while troubling to them, are neither dangerous or life-threatening and something they will have to learn to live with (see managing expectations, above).

9. Experience trumps education. So if the ICU nurse who’s been working for 10 years tells you a patient is sick, believe her.

10. When it comes to invasive procedures, from central lines to arthrocentesis to lumbar punctures, if you can’t get it in three tries, abort and call for help. There is sometimes a tendency to feel a sense of pride, as if it you against the internal jugular vein. But these procedures are not meant to be so difficult, and if they are, it’s time to give the patient a break and call someone with more experience to help. Your pride may sting, but your patient will thank you.

As I tell physicians in training, my high standards are the easy part: Taking the best possible care of patients is what matters.